A 48-year-old man with no prior medical history is admitted with community-acquired pneumonia and severe acute respiratory distress syndrome (ARDS). On day 1 of his illness, he is admitted to your ICU on:
volume control-assist control ventilation with a VT of 4 mL/kg IBW
On those settings, he is found to be hypoxemic with a SaO2 of 86% with an ABG that demonstrates:
Which of the following interventions is most likely to improve his survival?A. Prone positioning for at least 16 hours a day until oxygenation improves
Correct Answer: A
Although prior data were conflicting, a recent large, multicenter randomized controlled study of prone positioning in patients with ARDS within the first 48 hours demonstrated a significant reduction in mortality in the prone position group (answer A is correct). Although ECMO is increasingly employed as a rescue therapy in patients with severe ARDS and refractory hypoxemia, there have been no trials that demonstrate a significant mortality benefit (answer B is incorrect). PEEP titration using an esophageal balloon improves oxygenation and pulmonary mechanics in patients with ARDS but does not improve mortality. High-frequency oscillatory ventilation has been shown to potentially harm patients with ARDS (answer D is incorrect). Although inhaled pulmonary vasodilators improve oxygenation in patients with ARDS, there are not data that they improve survival (answer E is incorrect).